Basic Information
| Provider Information | |||||||||
| NPI: | 1982644779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUAEGEBEUR | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27036 | ||||||||
| Address2: | BHN ROOM 276 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100877036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052417 | ||||||||
| FaxNumber: | 2123425262 | ||||||||
| Practice Location | |||||||||
| Address1: | 3959 BROADWAY | ||||||||
| Address2: | BHN ROOM 276 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100321559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052417 | ||||||||
| FaxNumber: | 2123425263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 12/06/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 189014-1 | NY | N | Other Service Providers | Specialist | 208G00000X | 189014-1 | NY | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 1400664 | 05 | NY | MEDICAID |